America's approach to treating pain costs billions, leaves millions in pain and kills 17,000 a year

Dec. 16, 2013

Ellen Brinkerhoff, pictured with an MRI from 2011. / The Enquirer/Carrie Cochran

Written by

Lisa Bernard-Kuhn

The Cincinnati Enquirer

Commonly prescribed opioids

Hydrocodone: Available only in combination with other ingredients, hydrocodone-combination products are prescribed for different uses. Some hydrocodone is combined with acetaminophen are used to relieve moderate to severe pain. Vicodin, Lorcet and Lortab are among the brand-name versions of this drug. Other hydrocodone products are used to relieve cough. This is the most commonly prescribed opioid painkiller. Oxycodone: Used to treat people who are expected to need medication to relieve moderate to severe pain around the clock. It's also regularly combined with acetaminophen, and sold under brand names including OxyContin, Endocet, Roxicet and Tylox. Morphine: Prescribed to patients who are expected to need medication to relieve moderate to severe pain around-the-clock. Commonly prescribed brand names include MS Contin, Kadian and Avinza. Fentanyl: This potent opioid is delivered via skin patches to treat people who are tolerant to other narcotic pain medications. For more about each of these drugs, why they’re prescribed and their risks, visit: http://1.usa.gov/1hNrp2BSources: National Institute of Health; National Institute on Drug Abuse (NIDA); Drug Enforcement Administration (DEA)

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Stop running. Stop dancing. Stop climbing. Stop bending.

The doctor’s orders in 2011 stunned Ellen Brinkerhoff after he told her that her slightly curved spine was the likely source of more than 10 years of debilitating back pain that would leave her bedridden for days at a time.

Throughout her 20s, as she finished college and pursued a teaching career, Brinkerhoff saw “doctor after doctor” in her search for relief.

But each appointment produced the same result: a prescription for a muscle relaxer or a powerful opioid painkiller. Even with her new diagnosis of scoliosis, the doctor’s plan was the same.

“He told me, ‘Pain medication might be your best friend.’ ”

The advice to Brinkerhoff and countless others with bad backs, chronic headaches and a range of other troubles became standard in the past 15 years as U.S. doctors dramatically changed the way they treat pain. Driven by advocacy and education from the companies that make the pills, doctors have written millions of prescriptions for drugs including Vicodin, Percocet and OxyContin that contain compounds derived from opium, one of the world’s most powerful painkillers and most dangerous drugs.

The result has been a public health disaster.

The drugs don’t work for most people. Many patients, including Brinkerhoff, get little long-term relief and suffer significant side effects. Far worse, nearly 17,000 Americans die every year from prescription opioid overdoses, more than quadruple the number of a decade ago, according to the Centers for Disease Control and Prevention. Ohio’s toll was 1,154 opioid overdoses in 2011. In addition, legal painkillers are recognized as key gateway drugs to heroin, an illegal opioid whose supply exploded at the same time painkiller prescriptions boomed.

“Can you think of any other class of drug which killed 17,000 people in the U.S. and has no evidence that it works for most patients? There is none,” said Dr. Sairam Atluri, a pain management physician whoserves on a State Medical Board task force fighting prescription opioid abuse.

As part of its intensive reporting throughout 2013 on the opioid and heroin crises in our communities, The Enquirer spent months examining medical treatment of pain. Among the findings:

• For at least seven years, research has shown that prescription opioids hurt more people than they help even as sales of the drugs and the number of overdose deaths continued to rise.

• Doctors are poorly prepared to treat chronic pain or identify those who will truly benefit from opioids. Dr. Jeremy Engel, a primary care physician with St. Elizabeth’s Physicians in Bellevue, said, “You’re always hoping that you’re doing the right thing, but you don’t always know.”

• Doctors, who get paid for every office visit and prescription they write, lack incentives to try non-pharmaceutical approaches such as intensive physical therapy, massage and psychotherapy.

• The damage from prescription painkillers reaches all sectors of society. Surveys show 37 percent of high school students have tried a prescription drug not prescribed to them. Nearly one in five people 65 and older with chronic pain have reported abusing or being addicted to medicine prescribed to them. Suburbs, inner cities and rural areas are afflicted by pill and heroin addiction.

• Under pressure to reduce the flood of prescription opioids, regulators, health officials and policymakers have begun to act. New laws tightening prescribing standards have closed hundreds of “pill mills” in Ohio . The federal Food and Drug Administration is seeking tighter regulation of hydrocodone, and new labels warn about opioids’ risks of addiction and death. Still, industry analysts expect pain medication sales to continue growing.

• Companies that make the painkillers have spent millions backing organizations that advocated more aggressive treatment of pain, lead the education of doctors about pain treatment and, even today, offer coupons for new prescriptions.

• The U.S. Senate Finance Committee is investigating drug companies’ practices and their ties to the powerful Joint Commission, which sets accreditation standards for 20,000 health organizations and programs in the U.S. Pain treatment guidelines the commission instituted in 2001 are blamed by many doctors for fueling the opioid boom. The commission told The Enquirer it recognizes the crisis and is starting a review “to begin modifying or updating our pain management standards.”

'I was tired of just covering up the pain'

A share of the blame lies with our society’s notion that a pill is available to address any ailment. Americans, who make up less than 5 percent of the world’s population, consume 99 percent of the global hydrocodone supply and 83 percent of oxycodone, the two most common active ingredientsin prescription painkillers.

“We cannot be a nation in this much pain. Our pain is not different from other humans outside of the U.S.,” said Dr. Humam Akbik, director of Mercy Health’s Pain Management Center.

The fact is, most chronic pain sufferers will never be fully pain-free.

“If they’re in pain, they want to take a pill to make it go away. The concept of us working hard to achieve something has been taken over by ‘take a tablet and you’ll get what you want,’” Akbik said.

In Brinkerhoff’s case, after a decade of medication and recurrent pain, “I didn’t want another prescription. I was tired of just covering up the pain.”

A 2010 Cochrane Collaboration review of 26 studies of long-term opioid use found that many patients stop taking the drugs because of side effects and insufficient pain relief. The review also noted that only “weak evidence suggests that patients who are able to continue opioids long-term experience significant pain relief.”

Even for those who increase the dosage, studies show that most patients continue to suffer. In some instances, the drugs can even be the cause of more pain.

Atluri says he often tells his patients that long-term, high doses of opioids “may be harming you more than it’s helping.”

Research shows that the drugs cause hormonal imbalances in women. In men, “there is clear evidence” that opioids decrease testosterone levels, said Atluri. And elderly patients taking opioids have an increased risk of falling.

Other treatment options harder than prescribing drugs

Some approaches – such as acupuncture and massages – aren’t covered by health insurance. Others require lots of time from multiple physicians or lots of effort from patients.

“That’s a whole a lot harder to manage than just writing a prescription,” said Dr. Nancy Elder, a primary care doctor with UC Health and associate professor of family medicine at the University of Cincinnati.

The treatment challenge is compounded by a health care system that rewards doctors for their diagnosis, treatments and the number of prescriptions they write – rather than their patients’ health outcomes.

Part of the problem with chronic pain is that what helps one person doesn’t work for another.

“There is nothing out there that helps everybody,” said Atluri, adding that finding the best treatment can take months or years for patients and physicians.